A provider organization may do everything right in preparing for ICD-10—such as implementing good clinical document improvement programs and doing a top job training coders—yet still not reap the financial benefits of optimal payment under the new code set, and the fault could lie with insurers.

That could be a wrinkle in the promise of ICD-10, says John Elion, M.D, founder of ChartWise, a vendor of clinical document improvement software. For example, if a physician might perform a knee replacement surgery and properly documented all aspects of the procedure and justified the medical necessity. Everything is coded right, and the claim is sent to the payer.

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